This form is for Colorado licensed behavioral health services providers to request reimbursement for services provided to patients covered by the San Miguel Behavioral Health Fund, San Miguel Youth Fund and Recovery Access Fund. Tri-County Health Network will process requests and remit payments twice per month. Payment for requests submitted from the 1st to the 15th of the month will be mailed by the last day of the month. Payment for requests submitted from the 16th to the last day of the month will be mailed by the 10th of the next month. All of TCHNetwork’s behavioral health funds are a payor of last resort, please do not submit a request for reimbursement until all insurance claims have been paid. TCHNetwork will not reimburse any requests for payment for clients who miss their appointments. Providers must be licensed in the state of Colorado and must be approved for participation in the program before reimbursement can be paid. If a provider is not yet on the list, they can apply using the New Provider Application. For information on client scholarship status, start and end dates, and remaining sessions, please visit the Behavioral Health Fund ID Lookup page. If you have any questions, please contact Tri-County Health Network at BHFUND@tchnetwork.org.

Provider Information

Are you a Colorado licensed Social Worker, Marriage and Family Therapist, Psychologist, or Professional Counselor?*YesNo

STOP. Do not submit this request. You must be a Colorado licensed provider to be eligible for reimbursement through the San Miguel Behavioral Health Fund. If you have questions, please contact Tri-County Health Network at BHFUND@tchnetwork.org .

Colorado License Number*

Provider Name.*

Business Name (if applicable)

EIN

STOP. Do not submit this request. If you are not currently on this list, you must apply to be added. Please visit the New Provide Application. You will be asked to submit your current Colorado license and a W-9 form. Processing may take up to 10 business days at which time you may return to submit your request for reimbursement. This step is required in order to protect clients from receiving services that are not reimbursable by the San Miguel Behavioral Health Fund. If you have questions, please contact Tri-County Health Network at BHFUND@tchnetwork.org .

Email Address*

Phone Number*

PLEASE NOTE: Your billing address must match your W9.

Billing Address*

City*

State*

Zip*

PLEASE NOTE: Reimbursement will be sent to the address on your W-9. If your address has changed, please submit a new W-9 with the correct address to BHFUND@tchnetwork.org.

Billed Sessions

Client
ID*

Session
Date*

Start*

End*

Reason for Visit*
(ctrl+click for multiples)

Session Rate*

Scholarship Amount*

Client Portion*

Amount Billed*

Total Billed Amount*

Please verify that all session dates have been entered and there are no empty rows.

Electronic Signature Agreement

I certify, to the best of my knowledge, that all information in this request is true and accurate. I understand that all billed sessions are subject to verification and approval by Tri-County Health Network.

The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

Signature*

(Use your mouse or trackpad to sign.)

Printed Name*

Today's Date*